Transcript HIV / AIDS

HIV and Aging
JASON TOKUMOTO, MD
ASSISTANT CLINICAL PROFESSOR OF
MEDICINE
UNIVERSITY OF CALIFORNIA AT SAN
FRANCISCO
HIV / AIDS
 HIV(Human Immunodeficiency Virus): virus that
causes AIDS.
 AIDS(Acquired Immunodeficiency Syndrome) is the
term for HIV-infected individuals who have
advanced disease as defined by:
a. CD4 cell count less than 200.
b. Opportunistic infection.
Important Dates in HIV History-100 points
 September 18, 2009
Famous Writers-200 points
 This famous writer said:

“Forty is the old age of youth, FIFTY the youth of old age.”
HIV and Aging in the USA
 Currently, 25% of the estimated 1,000,000 people
infected with HIV(250,000) are =/> 50 years old.
 Currently, 15% of the new 56,000 individuals who
are diagnosed with HIV each year are =/> 50 years
old.
 By 2015, 50% of all HIV infected individuals will be
=/> 50 years old.
HIV and Aging—San Francisco
 53% of the 9,734 cases of HIV/AIDS in San
Francisco is > 50 years old.
Why the Increase?
 The number of individuals infected with HIV who
are =/> 5o years old is increasing due to:


Highly active antiretroviral therapy has made it possible for
many HIV-infected individuals to live longer.
Diagnosing more new HIV infections in older individuals.
Morbitidy and Mortality-300 points
 These individuals when given the diagnosis of being
HIV infected, tend to progress more rapidly to AIDS
and tend to have shorter survival rates when
compared to other groups diagnosed with HIV.
Diagnosing HIV in the older population
 Older individuals are more likely than younger
individuals to present late for HIV diagnosis, i.e. by
the time an older individual is tested positive for
HIV, they usually have advanced disease.
 In fact, diagnosis of HIV in older patients occurs
after the patient presents with an opportunistic
infection.
Diagnosing HIV in the older population
 Older HIV patients tend to progress more rapidly to
AIDS.
 Older HIV patients tend to have shorter survival
rates.
Reasons for not considering HIV in older
individuals
 Older individuals may not consider themselves to be
at high risk for HIV.
 Health care providers may not consider HIV in older
individuals.
SEX-400 points
 The group describes themselves as:
“Over 50, Still sexy, Still Smart.”
Reasons for not considering HIV in older
individuals
 False belief that older individuals are not sexually
active.
 Many clinicians do not ask older patients about their
sexual activity.


80% of older individuals are sexually active.
Only 38% of older men and 22% of older women reported that
they discussed their sex life with their provider.
Reasons for not considering HIV in older
individuals
 False belief that older individuals do not engage in
injection drug use.

16% of older HIV-infected patients acquire HIV through
injection drug use.
Reasons for not considering HIV in older
individuals
 Some signs and symptoms of HIV can mimic those of
normal aging so the provider may not have HIV in
mind as the cause of the signs and symptoms.



Fatigue
Weight loss
Mental confusion
Reasons for not considering HIV in older
individuals
 The latest CDC guidelines for HIV testing covers the
age from 13 year old to 64 years old.
Newly diagnosed older HIV patients-Linkage
and Retention
 Immediate linkage to care because there is a survival
advantage with regular HIV care.
 Equally important is retention in care.




Case management
Transportation
Mental health services
Drug treatment programs
Terminology-500 points
 Discrimination based on negative attitudes toward
aging and older people.
Management issues in the older HIV patient
 Ageism
 Multi-morbidity syndrome(not co-morbidity)
 Incorporating principals of geriatric medicine
 Antiretroviral therapy
 Frailty and HIV
 Does HIV speed up the aging process?
Ageism
 Discrimination based on negative attitudes towards
aging and older people.
Multi-morbidity syndrome
 Several serious health conditions that cannot be
cured( e.g. HIV infection, hypertension, diabetes
mellitus, malignancy) and engender functional
and/or cognitive debility.
Multi-morbidity
 Cardiovascular risk reduction
 Smoking cessation very critical intervention.
 High cholesterol/triglyceride reduction.
 Diabetes
 Avoid excess weight gain.
 Diabetes screening especially after starting antiretroviral
therapy.
Multimorbitity
 Kidney function
 Regular monitoring.
 If kidney function declining, need to assess for all possible
causes and consultation with a nephrologist is appropriate.
 Hypertension
 Should treat aggressively(decrease salt intake, weight, exercise,
medications) because hypertension can accelerate the
progression of cardiovascular disease, kidney disease, diabetes,
and increase the risk for stroke.
Multimorbidity
 Cancer screening
 Colorectal
 Cervical
 Prostate
 Osteoporosis
 Due to aging, HIV, antiretroviral medications
 Screening for and aggressive treatment
 Screen for vitamin D deficiency
Multimorbidity
 Sexual health
 Screen for high risk behavoir
 STD screening
 When taking a sexual history avoid judgemental attitudes and
ask the patient for permission to discuss sexual function
 Erectile dysfunction medications or topical estrogen for
vaginal dryness can enhance sexual satisfaction but must be
used with caution and should be linked to specific educational
efforts on safe sexual practices
Multimorbidity
 Neuro-cognitive changes

Increasing recognition of an overlap between HIV-associated
neurocognitive disorder(HAND) and Alzheimer’s disease
 Psychiatric Illness


Screen for depression and anxiety
HIV positive older patients are 5 times more likely to have
depression versus HIV negative older patients
 Substance abuse

No level of alcohol intake is known to be of benefit among HIV
infected individuals
Multimorbidity
 Psychosocial Issues
 HIV positive older individuals often have smaller and lower
functioning social networks than HIV negative older
individuals.
 In one study conducted in New York, 70% of older HIV
positive individuals lived alone which was twice the rate of
older HIV negative individuals.
Antiretroviral therapy
 The recommendations for initiating HIV therapy in
older patients is the same as those for the general
HIV-infected adult population.
 However, it is important to consider pre-existing
multimorbidities when customizing a regimen.
Antiretroviral therapy
 Generally have good immunological and virological
response.
 Because older individuals are generally diagnosed
with advanced disease, their CD4 cell count never
achieves levels to that of younger patients.
Antiretroviral therapy
Adherence
Polypharmacy
Side effects/drug tolerability
Is it aging(A), HIV(H), or antiretroviral
therapy(AT)?
 Neurocognition
 Cardiovascular disease
 High cholesterol/triglyceride
 Kidney disease
 Hypertension
 Glucose intolerance
 Osteoporosis
 Cancers
A
A
A
A
A
A
A
A
H
H
H
H
H
H
H
AT
AT
AT
AT
AT
Aging-1000 points
 What all of the following have in common: weakness,
fatigue/exhaustion, low physical activity, slowed
motor performance, weight loss, and DEATH.
Frailty-an important geriatric syndrome
 Weakness
 Fatigue/Exhaustion
 Low physical activity
 Slowed motor performance
 Weight loss(loss of muscle mass and bone mass)
MOST SERIOUS OUTCOME OF FRAILTY IS DEATH
Frailty and HIV
 Physiological parallels between frailty and HIV.
 Clinical parallels between frailty and HIV.
Physiological parallels between frailty and HIV
 Loss of repair capability
 DNA damage
 Sarcopenia(decrease muscle mass)
 Osteopenia(decrease bone mass)
 Immune function changes(loss of T cells)
Clinical parallels between frailty and HIV
 Weakness
 Fatigue
 Exhaustion
 Weight loss
 Slowed motor performance
 Poor physical activity
Underlying mechanism for the similarity between
frailty and HIV
 There is chronic systemic inflammation(constant
healing and destruction of cells and tissue) in both
frailty and HIV.
 Cytomegalovirus(CMV)
Inflammatory marker
 Both frailty and HIV have elevated levels of the
proinflammatory cytokine IL-6.
Does HIV speed up the appearance of clinical
frailty?
 Frailty much more common in HIV-positive males.
 Frailty prevalence for a 55 year-old male HIV-
positive for < 4 years is equal to an HIV-negative
male who is > 65 year-old.
Take home messages
 Older individuals are at risk for HIV.
 Therefore, have a low threshold for testing an older
individual for HIV.
 When seeing an older individual, always keep HIV
on your radar especially if there is a history of high
risk behavoir and/or signs/symptoms that could be
due to HIV.
 There is a need to target HIV testing and prevention
messages to older individuals.
 There is a need to educate older individuals about
HIV.
Take home messages
 Older individuals with HIV/AIDS have 3 risk factors
for multimorbidities: HIV, aging, antiretroviral
therapy.
 The presence and/or risk for these multimorbidities
has implications in the overall care of these older
patients.
 HIV may speed up the aging process due to chronic
inflammation.